1. Date of birth 2. Name of child 3. Sex 4. Race or color 5. Legitimate or otherwise 6. Alive or stillborn 7. Name of father 8. Nationality of father 9. Maiden name of mother10. Nationality of mother11. Residence of parents12. Occupation of father13. Name & residence of person reporting birth14. Reg. No.15. Page No. ( there are 4 certificates to a page.)

Transcribed from FHL film # 25362If you want a copy of the original, I can scan you one